Cycle 1
Health 2025-07-25 · Fire 2025-07-25
15 health deficiencies
Top issue: Administration (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Hancock, MI
Mission Point Nursing & Physical Rehabilitation Ce
1-star overall rating with 1-star inspections with Special Focus status with $180,775 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1400 Poplar Street, Hancock, MI
(906) 482-6644
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
39
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Point Healthcare Services
Operator or chain grouping
Approved since
1994-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.41
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.20
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.44
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,178
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.05
Performance 51.22% · Measure score 3.05 · Achievement 3.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.50
Baseline 2.81 hours · Performance 3.11 hours · Measure score 0.50 · Achievement 0 · Improvement 0.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 1 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 12.5% |
2.29%
10.2 pts worse
|
Numerator 3 · Denominator 24 · Adjusted rate 14.18% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 53 |
| Staff flu vaccination coverage | 8.57% |
42%
33.4 pts worse
|
Numerator 6 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.7
0.6 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.5
0.9 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
95.0%
3.7 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.4% · Q3 97.1% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.1%
1.6 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.1% · Q3 8.6% · Q4 2.9% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
4.1%
1.1 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.9% · Q3 6.1% · Q4 6.2% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.5%
0.6 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 9.4% · Q4 5.9% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
19.6%
3 pts better
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 18.4% · Q3 14.7% · Q4 14.7% · 4Q avg 16.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
16.5%
3.3 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 18.5% · Q3 20.8% · Q4 21.7% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
13.9%
7.6 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.1% |
11.7%
3.6 pts better
|
14.9%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 12.1% · Q3 10.3% · Q4 6.9% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.7%
1.7 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.6% · Q3 2.9% · Q4 2.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
20.4%
3.8 pts better
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 32.0% · Q3 13.5% · Q4 9.8% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.6%
0.8 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.5% · Q3 8.2% · Q4 5.1% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
82.8%
9.3 pts better
|
81.7%
10.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · 4Q avg 92.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
11.5%
6.5 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 5.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.5% |
1.3%
8.2 pts worse
|
1.6%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 9.5% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.2% |
24.2%
10 pts better
|
23.9%
9.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 15.0% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-12 · Fire 2024-08-12
29 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
20 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2023-07-14 · Fire 2023-07-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-07-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-12
E · Potential for more than minimal harm
2025-07-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-12
F · Potential for more than minimal harm
2024-08-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-25
F · Potential for more than minimal harm
2024-08-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-12
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-12
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-12
F · Potential for more than minimal harm
2023-07-14
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-07-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-21
F · Potential for more than minimal harm
2023-07-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-07-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-07-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-07-25
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-25
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-25
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-25
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-08-25
E · Potential for more than minimal harm
2024-12-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-06
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-06
L · Immediate jeopardy
2024-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-19
F · Potential for more than minimal harm
2024-08-12
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-09-12
F · Potential for more than minimal harm
2024-08-12
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-08-12
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-08-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
F942 · Resident Rights Deficiencies
Health
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-08-12
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-09-12
G · Actual harm
2024-05-01
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-05-01
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-29
D · Potential for more than minimal harm
2024-05-01
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-06-07
D · Potential for more than minimal harm
2024-04-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-04-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-26
F · Potential for more than minimal harm
2023-07-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-07-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-14
E · Potential for more than minimal harm
2023-07-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-14
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-07-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-14
Penalties and ownership
What sits behind the stars
$180,775
2024-08-12
Fine
Fine · fine $180,775
Fine
$0
2024-08-12
Payment Denial
Payment Denial · denial start 2024-09-06 · 13 days
13 day denial
Ownership
Mali, Hari
5% Or Greater Indirect Ownership Interest · Individual
Mission Point Northern Michigan Holding LLC
5% Or Greater Direct Ownership Interest · Organization
Mali, Hari
Corporate Officer · Individual
Mission Point Management Services LLC
Operational/Managerial Control · Organization
Rosenberger, Roberta
W-2 Managing Employee · Individual
Usitalo, Betty
W-2 Managing Employee · Individual
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